1. Acute coronary syndrome
Dr Wasantha Kapuwatta
MBBS. MD. MRCP

2. ACS
STEMI
NSTEMI UA

3. Clinical features Central Chest Pain at rest Radiation
Sweating , Vomiting
Cold clammy peripheries
Tachycardia
Low BP
Low SPO2

4. Diagnosis STEMI
ECG –
ST Elevation , New LBBB
Chest pain
Troponin

5. Diagnosis NSTEMI UA Chest Pain ECG Changers Troponin positive
Troponin Negative

9. Mx Of NSTEMI /UA Ideally first 24h in a CCU/ HDU Cardiac monitoring
O2 via mask
Spo2 < 94%
Features of Pulmonary oedema
IV cannular

10. Anti platelet RX
Anticoagulant
Aspirin 300mg
Clopidogrel 300mg
IV IIb/IIIa inhibitors ( Epitifibatide )
Aspirin 75 mg lifelong
Clopidogrel 75 mg one year
SC Enoxeparin 1mg/kg BD
SC Fondaparinex 2.5 mg daily
UFH

11. Pain relief
IV Morphine (.1mg /Kg)
GTN infusion

12. Statin B Blocker ACI PPI Atorvastatin 40mg Atenolol Bisoprolol
Enalapril
PPI
Pantoprazole

13. Investigations
FBS
Lipid profile
Renal function
FBC
2D Echo

18. Early PCI
Other patients
Features of heart failure
Low EF %
Continues chest pain
EX ECG in 6 weeks
Stress echo

19. STEMI

20. STEMI

23. Anti platelets Primary PCI Thrombolysis Aspirin 300mg
Prasugrel 60mg or
Clopidogrel 600mg
Aspirin 75mg
Prasugrel 10mg
Aspirin 300mg
Clopidogrel 300mg
Aspirin 75 mg
Clopidogrel 75mg

26. Comparison of thrombolytics
Streptokinase
Alteplase
Reteplase
Tenecteplase
Bolus No
Yes
Antigenic
Systemic fibrinogen depletion
Marked
Mild
Moderate
Minimal
90min patency rate
50%
75%
TIMI 3 flow
32%
54%
60%
63%
Cost(USD)
568
2750

28. How to assess Thrombolysis
Improve Chest pain
Improve HF
90 min ECG 50% reduction in STE
ISVR

29. Complications Cardiogenic Shock Acute ischemic MR Acute ischemic VSD
CHB VT
Polymorphic VT AF
Cardiac rupture
Dressler's syndrome
Pericardial effusion
Cardio renal Syndrome

32. CCU general care Cardiac monitoring IP/OP Level of consciousness
Arrhythmia VT, VF
BP , Pulse , RR
IP/OP
Level of consciousness
Patient bowel opening - if constipating need doctors attention to prescribe laxatives
Anxiety/ Insomnia - Anxiolitic

33. Communication Patient education What is a heart attract
Should start with the first medical contact
What is a heart attract
It’s a death part of heart muscle
What are the treatment plans
Cessation of smoking
Need to communicate to family members
These will improve patient / family anxiety

34. Diet - guidelines Easy digestibility Gastric emptying Low acidity
low protein
low fat
small quantities
Low acidity
for stress ulcers
When patient is haemodynamically stable
Chest pain free

35. Suggested plan of physical activity
Bed rest 24h (Allow exercise using mets.
Day 2 – Bed side chair.
Allow exercise using mets
Day 3 – Ward , uncomplicated primary PCI can discharged
Day 5 – Thrombolysed patient discharged
Allow exercise using 3-5mets

36. Physical activity using 2-4 mets
Walking – 3km/hr
(i.e. 3 feet/sec)
Dressing (2-3mets)
Washing a plate
Washing a handkerchief
Washing and shaving
Bed pan (4-4.5mets)
Bedside commode
(3-3.5mets)
Playing piano etc.
Reading (1.5mets)
Arranging articles on shelf
Cutting vegetables
Watching television
Ironing a banion, hanky
Playing cards (1.5)
Billiard (2.5)
Write at a desk (1.5-2)
Gardening
Sweeping floor
(3-5)

37. When can you- Climb 2-3 steps – on discharge
Climb 1 flight of stairs – 7 days
Climb 2 flights of stairs quietly or 1 flight of stairs rapidly– 3 weeks (6 mets)
Cycle at 8 km/hr – 8 weeks
Carry 5kg weight – on discharge
30kg weight – 8 weeks

38. Driving Light vehicles
If successfully treated by coronary angioplasty, driving may recommence after 1/52 provided:
no other URGENT revascularisation is planned(URGENT refers to within 4/52from acute event)
LVEF is at least 40% prior to hospital discharge
there is no other disqualifying condition
If not successfully treated by coronary angioplasty, driving may recommence after 4/52 provided:

39. Driving Heavy vehicles
All Acute Coronary Syndromes disqualify the licence holder from driving for at least 6/52.
Re/licensing may be permitted thereafter provided:
the exercise or other functional test requirements can be met
there in no other disqualifying condition

40. Sexual activity
Most patients regard restoration of sexual activity as the norm of reaching ‘normality’.
Younger the patient, greater is the increase in heart rate during sexual activity:
younger couple – male bpm,
female bpm
older couple – male/female bpm.
This increase lasts 4-5 minutes after orgasm.
Thus the ability to reach a heart rate of 135bpm at ExECG indicates safety of sex.

41. Sexual activity The two main problems in sex are Angina
Arrhythmias (as palpitations)
Precipitation of a second infarct or sudden death is of serious concern to patients.
Ueno et al(1963) – sudden death during sexual intercourse is
rare, i.e.0.6% of all cardiac deaths.
For this study most of the deaths occurred after excessive
consumption of alcohol and in extra marital affairs.

42. Sexual activity ctd Usually safe at 4-6 weeks post MI.
Mets utilized vary from 4.5-6
If ExECG has not been done, climbing 2 flights of stairs quickly is given as equal use of mets.

43. Discharged advice
Continue medications especially Aspirin and Clopidogrel
Stop smoking
Dilatory advice
How to use GTN
Importance of DM, HT, HL control
Next clinic visit date
Future plans

44. Drug on discharge Aspirin 75-150mg
Clopidogrel 75mg ( Prasugrel 10mg if primary PCI)
Statin ( Atorvastatin)
B Blocker ( Carvedilol , Bisoprolol)
ACI ( Ramipril , Enalapril )
PPI ( Pantoprazole)